同期杂交手术治疗复杂Stanford B型主动脉夹层

目的回顾性分析同期杂交手术治疗复杂Stanford B型主动脉夹层的手术方法及疗效，探讨基层医院施行该手术的可行性。方法2010年12月至2013年3月襄阳市中心医院胸心外科对7例复杂Stanford B型急性主动脉夹层患者施行同期杂交手术治疗。男2例、女5例，年龄45～64（50．0±8.3）岁。术前主动脉CT血管造影（CTA）示主动脉夹层破口距左锁骨下动脉开口〈15mm 4例，累及左锁骨下动脉开口3例，其中1例合并胸主动脉壁多部位钙化，冠状动脉CTA示前降支近中段狭窄约70％。采用气管内插管静脉复合麻醉，手术室先期行颈部切口完成主动脉弓分支旁路手术，术毕转送导管室行股动脉切口完成主动脉腔内修复术，冠状动脉粥样硬化性心脏病患者同期完成前降支支架植入术。结果所有患者均成功完成手术，并植入覆膜支架。1例术后发生少量Ⅰ型内漏。围术期无死亡和严重并发症发生。术中CTA证实主动脉夹层真腔血流恢复正常，旁路血管血流通畅，支架植入定位准确，支架无明显移位。随访7例，随访时间3～24（12．0±3．6）个月，所有患者均生存，恢复正常生活。6例术后3个月及术后1年或2年复查主动脉增强CT示支架无移位和内漏，支架内及人工血管旁路血流通畅；1例少量Ⅰ型内漏患者术后3个月复查假腔内仍有造影剂显示，但部分血栓形成，假腔程度及范围较术前变小，真腔明显增大，术后6个月复查内漏消失。所有患者未见脑部和肢体缺血征象。结论复杂Stanford B型主动脉夹层采用同期杂交手术治疗安全、有效，扩大了介入覆膜支架腔内治疗的适应证，在基层医院值得推广应用。

One-stage Hybrid Surgery for Complex Stanford Type B Aortic Dissection

Objective To review clinical techniques and outcomes of one-stage hybrid surgery for complex Stanford type B aortic dissection （AD）, and explore the feasibility of this surgery in basic-level hospitals. Methods Seven patients with complex Stanford type BAD underwent one-stage hybrid surgery from December 2010 to March 2013 in Department of Cardiothoracic Surgery of Xiangyang Central Hospital. There were 2 males and 5 females with a mean age of 50.0±8.3 years. Preoperative computed tomography angiography （CTA） found that the distance between breach and left subclavian artery opening was less than 15 mm in 4 patients, and left subclavian artery root were involved in 3 patients. One patient had several calcification sites of the thoracic aorta and coronary arterial stenosis near the middle segment of anterior descending coronary artery by about 70%. All the patients received general anesthesia and endotracheal intubation. Firstly, bypass surgery of the branches of the aortic arch was performed via neck incision in the operating room, then endovascular aortic repair （EVAR） using femoral artery incision was performed in the catheter room. The patient with coronary artery disease received concomitant stenting of the anterior descending artery. Results All the patients successfully received the operation and EVAR. Postoperatively, 1 patient had mild type ｜ endoleaks. No death or severe complication occurred in this group. Intraoperative angiography showed that blood flow in true lumen of AD became normal, all the bypass grafts were unobs- tructed, the positioning of stent grafts was accurate, and no stent displacement was found. All the 7 patients were followed-up for 3-24 （ 12.0 ± 3.6） months, and all the patients were alive and resumed normal life during follow-up. In 6 patients, CTA at 3 months, 1 year or 2 years after the operation showed no stent graft translocation, endoleak, bypass or graft obstruction.In 1 patient with type I endoleaks, CTA at 3 months after the operation showed contrast agent in the false lumen, but partial thrombosis occurred, the size and scope of false lumen were smaller than preoperative values, and the true lumen significantly became larger. CTA at 6 months after the operation showed that leakage had disappeared. None of the patients had any sign of brain or limb ischemia. Conclusion One-stage hybrid surgery is safe and effective for the treatment of complex Stanford type BAD, expands the treatment indications of EVAR, and is worthy of widely application in basic-level hospitals.